1
Session 99, February 13, 2019
Stefanie Lin, RN/Clinical Analyst, Cleveland Clinic
Christine V. Chambers BS, MT, Donation Coordinator, Cleveland Clinic
Novel EHR Tools to Assist with
Organ Procurement Workflows
2
Stefanie Shimko-Lin, RN
Christine V. Chambers, BS, MTS
Have no real or apparent conflicts of interest to report.
Conflict of Interest
3
What if?
Organ Procurement Organizations
Legal Requirements
Barriers to Organ Donation
Team Roles
Previous Workflow
Solution
User Feedback
Other Opportunities…Real World
Agenda
4
Discuss the importance of the organ donation referral process and
how it relates to the Electronic Medical Record (EMR)
Explain how documented data within the EMR can be used to
consistently identify a specified population
Identify clinical issues where use of innovative tools provide
quality outcomes and efficient shared clinical workflows to meet
the needs of several disciplines
Learning Objectives
5
What if?
6
By United States Federal Law - OPOs are the only organizations
that can perform the recovery of organs from deceased donors
for transplantation
OPO services include donor family support, clinical management
of organ donors, and professional and public education.
All OPOs are regulated by multiple government agencies and
adhere to the highest medical and ethical standards.
58 OPOs in the United States
Organ Procurement Organizations (OPOs)
Association of Organ Procurement Organizations. (2018, October 31). About OPOs.
Retrieved from http://www.aopo.org/about-opos/
7
Center for Medicare and Medicaid Services (CMS)
Organ Procurement and Transplantation Network (OPTN)
United Network for Organ Sharing (UNOS)
Food and Drug Administration (FDA)
Regulating Bodies for OPOs in the United States
Association of Organ Procurement Organizations. (2018, October 31). About OPOs.
Retrieved from http://www.aopo.org/about-opos/
8
Centers for Medicare and Medicaid Services
Requirements
Hospitals that receive reimbursement from Medicare and/or Medicaid
must notify their local organ procurement organization (OPO) of all
deaths and *imminent deaths in a **timely manner. (CMS §482.45(a)(1))
Hospitals are required to maintain a patient hemodynamically until OPO
is able to evaluate the potential donor and the donation request can be
made to the family. (CMS §482.45(a)(5))
*Imminent death is defined as a mechanically ventilated patient with a devastating
neurological injury or insult and missing at least two brain stem reflexes or a
Glasgow Coma Scale of 5 or less.
**Timely is defined as within one hour.
Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-
content/uploads/2018/07/Donor-Resource-ManualV1.pdf
9
Centers for Medicare and Medicaid Services
Requirements
The perception that a family's grief, race, ethnicity, religion or socioeconomic
background would prevent donation should never be used as a reason not to
approach a family about donation. (CMS §482.45(a)(3-4))
It is [OPO] responsibility to determine medical suitability for donation and
must evaluate every patient who meets initial criteria for donation.(CMS
486.344(b)(4))
Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-
content/uploads/2018/07/Donor-Resource-ManualV1.pdf
10
Non-compliance and Low Referral Rate
Implications
Reduced organ, tissue and eye availability for patients in need of transplants
Hospitals can be fined for non-compliance.
Reports of low referral rates can be reported to CMS and a CMS Survey may
be conducted
11
Every ten minutes, someone is added to the national transplant waiting
list.
On average, 20 people die each day while waiting for a transplant
People need a lifesaving organ transplant (total waiting list candidates)
Association of Organ Procurement Organizations. (2018, October 31). About OPOs. Retrieved from
http://www.aopo.org/about-opos/
12
Image Source Noun Projet
Donor
Saves Up to 8 Lives
Enhances 50+ Lives
Lifebanc. (2018, July). Donor resource manual. Retrieved December 15, 2018, from http://www.lifebanc.org/wp-
content/uploads/2018/07/Donor-Resource-ManualV1.pdf
13
Low rate of family consent
Family concerns about religious, cultural and social beliefs
Family concerns about body integrity and exact time of death
Family emotional vulnerability
Education, income, sex, and age of family members
Late or non referrals due to missed indicators or time to make calls
Barriers to Donation
Bocci, M., D'Alò, C., Barelli, R., Inguscio, S., Prestifilippo, A., Di Paolo, S., … Sandroni, C. (2016). Taking
Care of Relationships in the Intensive Care Unit: Positive Impact on Family Consent for Organ
Donation. Transplantation Proceedings, 48(10), 3245-3250. doi:10.1016/j.transproceed.2016.09.042
14
Work collaboratively with the healthcare team
Review entire ICU population for health system continuously
Make referrals to OPO in a timely manner
Provide education about donation and transplantation to patient
families and obtain Organ Donation Consent
Develop appropriate communication plans
Support families
Help and maximize the gifts of donation and transplantation.
Role of Single Donor Coordinator
15
Review 691 ICU population for health system continuously for referrals
Call in all hospital deaths to OPO
Coordinate with Medical Examiner’s Office – all approvals and sign off for release of
every patient that dies in the hospital over 1600 in 2018
Perform a in depth chart review for compliance with Ohio law for deaths reportable to
Medical Examiner and Adult Protectives Service concerns
Bedside meetings with family before and after death
Emotional support, hand holding, and active listening to families facing end of life for
a loved one
Coordinate with family to help navigate end of life concerns such as funeral home,
belongings, and autopsy options after death
Role of Four Family Liaisons
16
Act as a family resource for any issues family may have after patient dies
Help family with autopsy information and retrieving records
Family support and resources - provide a soft place to get things handled in place
after death
Coordinate special needs religious or otherwise the family may request
Help find resources for cremation if family has financial need
Assistance with body donation support if family chose body donation
Process all invalid advanced directives and communicate through mail with patients
to clarify and correct invalid advance directives for all regional hospitals
Coordinate removal of abandoned bodies for regional and main hospitals
`
Role of Four Family Liaisons Cont.
17
Bedside nurse identifying patients on a ventilator, with a Glasgow Coma
Score (GCS) less than 5 or 2 missing brain stem functions, and a
qualifying neurological injury and making the referral call
OPO contacted only after patient expired or been extubated, disqualifying
patients based on non-timely referrals
Family Liaisons reviewing ICU patient charts for qualifying data manually
Clinician referrals to Donor Coordinator or Family Liaisons in ICUs
Constant chart review on patients in ICU settings
OPO referrals made when patients identified with all three qualifiers for
referral were identified as being met through manual process or Brain
Death or Cardiac Death was reported.
All documentation performed on paper and not stored in EMR
Previous Workflow for Referral Identification
18
So what’s the problem?!?!
Many
patients
Information
Overload
Limited time Frame
Miscommunication
and Missed
Communication
Inconsistent Workflows
Limited Staff
Missed Opportunities
19
Surface discrete data consistently filed on each patient
Use data in a filter to show only patients who are referral appropriate
GCS coma score less than 5
Patient on a ventilator
Neurological diagnosis or qualifying other diagnosis such as cardiac
arrest in active problem list
Solution
Close workflow loop and communicate referrals to all workflow users
One report shows all information needed by OPO, referring user, eHospital
etc in one place rather than manual search in chart
Call information documented in one location can be seen by all involved in
referral process and patient care
20
New look, one location - Custom patient list filters out
patients not appropriate, shows qualifying factors of on
Vent, GCS less than 5 or two missing brainstem functions
21
Fill out call information in one location
Call column allows user to fill in information and all other users
can see when call made and who was spoken to
22
One Report Used for All
23
No discrete documentation of time of death
Inconsistent use of workflow
No discrete documentation of brain stem function assessment
Buy-in from Clinicians
Closed loop with all those involved in patient care
Correct identification of qualifying diagnosis
Metrics
Problems Encountered
24
Measuring Success
25
Quotes from workflow users
“The algorithm has made the progress of searching for patient's
appropriate to refer to Lifebanc much easier and continues to
improve we work to sharpen the mechanisms used in the
algorithm. Very pleased with the efforts to date and those
forthcoming.”
“This new format is way easier to interface with. It keeps it simple,
and straight-forward.”
“It is very helpful to be able to find the GCS without actually
opening the pt's chart. But with this tool, we can hover over a
column on EPIC patient list and GCS pops up. This allows me to
decide whether or not to open a patient's chart in certain cases.
For example, if a person codes overnight, the arrest may not show
up in the 'problem list', so the algorithm may not pick up the case.”
26
Situational Awareness
Gradual changes in vital signs
Mobile Device integration and bidirectional workflows
Prioritization of patient care
Reduction of Infection
Care Bundle tracking
Other Opportunities
27
Abby
Permission to share photographs obtained.
June 23, 1994 - April 25, 2018
28
Today, we share a common space and join in a common cause.
Through the caring touch of our hearts and hands, we join our efforts to
care for all donor patients and for all who benefit from the gift of life.
For all the children, grandchildren, friends, and family who are touched
by what we do here today, may we remember that fresh hope and
dreams began with the gift of one person.
May we take a moment now, in silence, to honor the lives of those who
gave a stranger life.
Moment of Honor
Lifebanc Moment of Honor, read in the Operating Room prior to organ retrieval.
29
Lifebanc Donor Resource Manual
http://www.lifebanc.org/wp-content/uploads/2018/07/Donor-
Resource-ManualV1.pdf
Association of Organ Procurement Organizations
http://www.aopo.org/find-your-opo/
International Society for Organ Donation and Procurement
https://www.tts.org/isodp/resources/organ-donation-societies
The Alliance Leadership in Organ Donation and Transplantation
Organ Donation Toolbox https://organdonationalliance.org/organ-
donation-toolbox/
Resources and Additional Info
30
Please remember to complete your online session evaluation.
Stefanie Shimko-Lin, RN Clinical Analyst
Cleveland Clinic
shimkos@ccf.org
https://www.linkedin.com/in/stefanie-lin-rn-a2b80a81/
Christine V. Chambers, BS, MTS Donor Coordinator
Cleveland Clinic
chambec1@ccf.org
https://www.linkedin.com/in/christine-chambers-monkowski-538382136/
Questions